Healthcare Provider Details

I. General information

NPI: 1447788476
Provider Name (Legal Business Name): SHANNON M KOCH MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2017
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 N MAIN ST STE 220
CHELSEA MI
48118-1370
US

IV. Provider business mailing address

3884 5 MILE RD
SOUTH LYON MI
48178-9697
US

V. Phone/Fax

Practice location:
  • Phone: 734-433-5100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301017089
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301017098
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6361007528
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: